HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 12/5/2022 BEt;E1VEU
Commonwealth of Massachusetts
City/Town of SEC 052022
System Pumping Record alloO"EV
Form 4 �OHEa THUEPARTM�NT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The.Syste.m Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. -
HOUSE: ack side rear left ' ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer,
use only the tab
key to move your A re cursor-do not �,wn t e �✓� LJ /�`'"/�
use the return i�tY�orw�n State Zip Code
key.
2. System Owner:
'Iffl k-e
Name
mmn '
Address(if different from location)
City/'Town State Zip Code
Telephone Number
B. Pumping Record (�
1. Date of Pum in _
p g ate 2 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YesANo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
MAh* 6&ee�,,d on-w T—o
6. System Pumped By: ��
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. a I where contents were disposed:
GLS
Signature of HaulerDate —
Signature of Receiving Facility(or attach facility receipt) Date — -- —
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